The Child with a Limp DR S Rajapaksa RCH CHIld with a limp
Case: An 11 year old presents to ED with a 4 days history of a painful limp. He had been playing footie over the weekend and had fallen but then got up to play again. He has no history of recent infection or fever He weighs 70kg
What else would you want to know?
Case He has no past medical history; IUTD and no allergies He has pain in his left knee when walking On examination, the ED resident, Jane notes a limp but can find nothing else on examination to explain his predicament She orders a pelvic XR
Would you do anything differently?
What do you think?
What is your differential list?
Case He is sent home with the diagnosis of a thigh sprain He is booked to paediatric clinic in view of his obesity The family do not attend the paed registrar clinic. He is seen in ED 4 weeks later with ongoing limp and can no longer weight bear on his left leg
Case He is seen by the ED consultant who notices that he keeps his left leg in external rotation and has limited hip movement on that side He orders an AP and frog lateral hip XR
What is your diagnosis?
Bilateral SUFE SLIPPED UPPER FEMORAL EPIPHYSIS or SLIPPED CAPITAL FEMORAL EPIPHYSIS
Case He is referred to orthopaedics He requires surgery on both hips more intensive that pinning the head of the femur in the joint as the SLIPs are extensive. How do you think this case could have been managed better?
Improvements Better differential diagnosis Frog Lateral XR (as AP will miss early SUFE) Documented advice to return early if not improvement Review and discussion with a senior doctor prior to discharge which must be documented
What is SUFE?
SUFE RCH SUFE CPG Usually occurs at the onset of puberty (12-15 years) Esp tall and thin short and obese Afro-Caribbean boys family history. One quarter of cases are bilateral Hip, thigh and knee pain. Often initially a several week history of vague groin or thigh discomfort. May be able to weight bear, but is painful. Flexion of hip often also causes external rotation. May be leg shortening.
Other differentials Perthe s - RCH Perthe information Trauma resulting in a fracture/ stress fracture Rheumatological disorder Muscle sprain Referred pain eg abdominal/ back/ genitalia
Case 2 A 4 year old boy, Sam, presents to ED with a 3 day history of fever and a 24 hour history of limping and wanting to be carried. He screams if someone touches his leg. The whole family have been suffering from URTIs In ED, temp 37.6, sats 98%, HR 120 and RR 30 What is your differential? What would be your management?
Case 2 He is seen by the intern, Dan, who struggles to examine the child as he screams anytime the doctor or nurse approaches. There is no history of trauma He is developing normally IUTD and NKDA He has a younger 6 & 18 month old sisters at home and the mother is keen to get home asap to relieve the baby sitter.
Examining the distressed child Analgesia Paracetamol Ibuprofen Distraction Bubbles Videos/ music Examine the parent/ favourite toy first Return when calmer Get help from another person parent, doctor, nurse
Case 2 The intern speaks to the ED registrar who advises ibuprofen The intern is worried about septic arthritis Do you agree with this diagnosis? What is your management?
Case 2 The intern orders a AP hip XR he looks at the film and believes it is normal. He attempts to take blood for CRP, FBE Do you agree with this plan?
Case 2 He is unsuccessful with the bloods. After pain relief, Sam is alert and happily playing on his mother s smart phone. Sam s mother is keen to go home to see her younger daughters and is pestering Dr Dan to be discharged. Dr Dan now believes this is Transient Synovitis as the child looks so well and discharges Sam Do you agree with this plan?
Case 2 3 days later Sam and his mother return to ED. He has continued to spike fevers, presents with temp 40 and is lethargic. He is refusing to walk What is your differential diagnosis?
Case 2 Sam receives pain relief (ibuprofen and paracetamol) He has no active or passive movement of the right leg He has no rashes He is mildly dehydrated Temp 40, RR 30, HR 136, sats 100%, BP s85
Case 2- Management: Analgesia IV access FBE (WCC 18), CRP (93), ESR (100), blood cultures, blood film (excludes ALL), UEC Hip XR (normal)and US Orthopaedic review Diagnosis: SEPTIC ARTHRITIS He is taken to theatre for a hip washout after the US shows significant effusion and? Pus His BC and joint fluid grow staph aureus
How do you think this case was managed? What could have been done better?
Improvements Missed key points in history and examination Would have benefitted from senior input (was not working within his competency) Didn t consider all differentials Inadequate investigations Falsely reassured by child being afebrile in ED and improvement following pain relief without completing examination Pressured by mother s desire for discharge and failed to complete full assessment Clear documented instructions for review if not improving
Septic arthritis & osteomyelitis RCH Septic arthritis & osteo CPG Commonly hip, knee, ankle, shoulder, elbow. Most often children <2yrs. Early features often non-specific Child often very unwell. Pain often present at rest, resistance to attempted movement of the hip. Older children usually reluctant to weight bear, may be more aware of referred pain in the knee. Hip is kept flexed, abducted and externally rotated.
What are the likely organisms?
Septic arthritis/ osteomyelitis Etiology Staph aureus Group A Strep Kingella kingae Neonates: E. coli, Candida, GBS Adolescents: N. Gonorrhea Sickle cell - Salmonella Usually hematogenous seeding Extension of osteomyelitis Direct inoculation into joint from penetrating trauma
Differentials Transient synovitis Trauma and fracture HSP Referred pain abdomen; genitalia; neurological eg GBS
Transient synovitis RCH Transient synovitis Non-infectious, inflammatory condition Usually children 3 8yrs May follow viral URI Mild fever, limp, fussiness Minimal limitation of range of motion passively ESR, CRP, WBC usually normal Managed with rest, NSAIDs, close follow up
RED FLAGS! Child <3y Unable to weight bear Fever Systemic illness >9y with pain or restricted hip movements
Examining a child s gait - pgals pgals - video of examining child's musculoskeletal system RCH PGALS pdf
Resources Check out the following resources for tips on history taking; differentials and investigation and management RCH child with limp CPG RCH acutely swollen joint CPG RCH Paediatric fractures CPG